Erken dönem Kienböck hastalığının (evre 1-3A) 4+5 ekstansör kompartman vaskülarize kemik grefti ile tedavisi

Abstract

Amaç: Kienböck hastalığı lunat kemiğin avasküler nekrozu ile karakterizedir ve etiyolojisi halen tartışmalıdır. Vaskülarize kemik grefti (VKG), erken evre hastalıkta vaskülariteyi artırmak ve karpal fonksiyonları korumak amacıyla cerrahi bir seçenek olarak öne çıkmıştır. Bu çalışmanın amacı, 4. ve 5. ekstansör kompartman arterleri (ECA) temelli pediküllü VKG ile tedavi edilen evre 1–3A Kienböck hastalığı olgularının klinik ve fonksiyonel sonuçlarını değerlendirmektir. Gereç ve Yöntem: Bu retrospektif kohorta, 2017–2023 yılları arasında tedavi edilen 22 hasta (7 evre 1, 9 evre 2, 6 evre 3A) dahil edildi. Cerrahi teknikte distal radiustan alınan kortikospongiyöz greft, 4+5 ECA pedikülü ile lunat defektine transfer edildi. Ameliyat sonrası 4–6 hafta kısa kol atel uygulandı ve ardından fizyoterapi başlatıldı. Sonuçlar preoperatif ve postoperatif 12. ayda değerlendirildi: el bileği fleksiyon–ekstansiyon arkı, ulnar–radial deviasyon, kavrama gücü, Görsel Analog Skala (VAS, 0–100 mm) ve QuickDASH skorları. Gruplar içi karşılaştırmalar eşleştirilmiş T-testi veya Wilcoxon testi ile, evreler arası karşılaştırmalar ise Kruskal–Wallis testi ile yapıldı. Bulgular: Bir yıllık takipte anlamlı iyileşmeler izlendi: fleksiyon–ekstansiyon arkı (90.05°→128.00°, p=.000), ulnar–radial deviasyon (32.05°→37.60°, p=.000), kavrama gücü (23.59→37.59 kg, p=.000), VAS (65.23→22.45, p=.000) ve QuickDASH (55.60→19.60, p=.000). Alt grup analizinde her evrede (1, 2 ve 3A) tüm parametrelerde anlamlı düzelme saptandı (p=.000). Evreler arası karşılaştırmalarda anlamlı fark bulunmadı (tüm p>.05). Üç hastada (%13.6) yüzeyel yara enfeksiyonu görüldü ve oral antibiyotik ile düzeldi. Donör saha morbiditesi, nörovasküler komplikasyon veya greft kaybı izlenmedi. Sonuç: 4+5 ECA temelli pediküllü vaskülarize kemik grefti, erken evre Kienböck hastalığında güvenli ve etkili bir tedavi seçeneği olup, minimal komplikasyon oranı ile anlamlı fonksiyonel iyileşme ve ağrı kontrolü sağlamaktadır. Evre 1–3A hastalarında elde edilen iyileşme düzeyleri benzer olup, bu evreler arasındaki hastalık şiddetinin kısa dönem sonuçları belirgin şekilde etkilemediği görülmüştür. Uzun dönem etkinliği değerlendirmek ve bu yöntemi alternatif cerrahi seçeneklerle karşılaştırmak için daha geniş örneklemlere sahip prospektif çalışmalara ihtiyaç vardır.

Keywords

• Kienböck
• Lunatum
• Avasküler nekroz
• 4+5 ekstansör kompartman

Management of early-stage Kienböck disease (stages 1–3a) with vascularized bone grafting

Abstract

Aims: Kienböck’s disease is characterized by avascular necrosis of the lunate, with its etiology still debated. Vascularized bone grafting (VBG) has emerged as a surgical option for early-stage disease to improve vascularity and preserve carpal function. This study aimed to evaluate clinical and functional outcomes of stage 1–3A Kienböck’s disease treated with a pedicled VBG based on the 4th and 5th extensor compartment arteries (ECAs). Methods: This retrospective cohort included 22 patients (7 stage 1, 9 stage 2, 6 stage 3A) treated between 2017 and 2023. Surgical technique involved harvesting a corticospongious graft from the distal radius, transferred on the 4+5 ECA pedicle into the lunate defect. Postoperatively, a short-arm splint was applied for 4–6 weeks, followed by physiotherapy. Outcomes were assessed preoperatively and at 12 months: wrist flexion–extension arc, ulnar–radial deviation, grip strength, Visual Analog Scale (VAS, 0–100), and QuickDASH. Paired comparisons were performed with the paired T-test or Wilcoxon signed-rank test; comparisons among disease stages (stage 1, stage 2, and stage 3A) were performed using the Kruskal–Wallis test. Results: At one year, patients demonstrated significant improvements: flexion–extension arc (90.05°→128.00°, p<.001), ulnar radial deviation (32.05°→37.60°, p<.001), grip strength (23.59→37.59 kg, p<.001), VAS (65.23→22.45, p<.001), and QuickDASH (55.60→19.60, p<.001). Subgroup analysis confirmed significant within-stage improvements (p<.001for all parameters). Interstage comparisons revealed no statistically significant differences in outcomes (all p>.05). Superficial wound infection occurred in three patients (13.6%) and resolved with oral antibiotics. No donor-site morbidity, neurovascular complications, or graft failures were observed. Conclusion: The 4+5 ECA-based vascularized bone graft appears to be a safe and effective option for early-stage Kienböck’s disease, providing meaningful short-term clinical and functional improvement with a low complication rate. However, due to the retrospective design and the absence of standardized radiological outcome measures, the present findings should be interpreted as short- to mid-term clinical results rather than evidence of radiological revascularization or prevention of disease progression. Further prospective studies with larger cohorts are warranted to confirm long-term efficacy and to compare this technique with alternative surgical strategies.

Keywords

• Kienböck
• lunate
• avascular necrosis
• 4+5 extensor compartment

References

1. Nasr LA, Koay J. Kienbock Disease. In: StatPearls. Treasure Island (FL): StatPearls 2023.
2. Chojnowski K, Opiełka M, Piotrowicz M, et al. Recent advances in assessment and treatment in Kienböck's disease. J Clin Med. 2022;11 (3):664. doi:10.3390/jcm11030664
3. Schiltenwolf M, Martini AK, Mau HC, Eversheim S, Brocai DR, Jensen CH. Further investigations of the intraosseous pressure characteristics in necrotic lunates (Kienböck's disease). J Hand Surg Am. 1996;21(5):754-758. doi:10.1016/S0363-5023(96)80187-0
4. Low SC, Bain GI, Findlay DM, Eng K, Perilli E. External and internal bone micro-architecture in normal and Kienböck's lunates: a whole-bone micro-computed tomography study. J Orthop Res. 2014;32(6):826-833. doi:10.1002/jor.22611
5. van Leeuwen WF, Janssen SJ, ter Meulen DP, Ring D. What is the radiographic prevalence of incidental Kienböck disease?. Clin Orthop Relat Res. 2016;474(3):808-813. doi:10.1007/s11999-015-4541-1
6. Mennen U, Sithebe H. The incidence of asymptomatic Kienböck's disease. J Hand Surg Eur Vol. 2009;34(3):348-350. doi:10.1177/1753193408098481
7. Kazmers NH, Yu Z, Barker T, Abraham T, Romero R, Jurynec MJ. Evaluation for Kienböck disease familial clustering: a population-based cohort study. J Hand Surg Am. 2020;45(1):1-8.e1. doi:10.1016/j.jhsa.2019. 10.005
8. Daly CA, Graf AR. Kienböck disease: clinical presentation, epidemiology, and historical perspective. Hand Clin. 2022;38(4):385-392. doi:10.1016/j.hcl.2022.03.002

9. Mohan A, Knight R, Ismail H, Trail IA. Radiographic and computed tomography correlation of Kienböck's disease: is there a need to revisit staging with improved ımaging?. J Wrist Surg. 2020;9(1):39-43. doi:10.10 55/s-0039-1688993
10. Bouri F, Hantouly AT, Alzobi O, et al. Clinical and radiological outcomes of scaphocapitate fusion in Kienböck disease: a systematic review and meta-analysis. J Hand Surg Glob Online. 2023;5(4):435-444. doi:10.1016/j.jhsg.2023.03.014
11. Arnaiz J, Piedra T, Cerezal L, et al. Imaging of Kienböck disease. AJR Am J Roentgenol. 2014;203(1):131-139. doi:10.2214/AJR.13.11606
12. Nealey EM, Petscavage-Thomas JM, Chew FS, Allan CH, Ha AS. Radiologic guide to surgical treatment of Kienbock's disease. Curr Probl Diagn Radiol. 2018;47(2):103-109. doi:10.1067/j.cpradiol.2017.04.012
13. Bartelmann U, Kalb K, Schmitt R, Fröhner S. Radiologic diagnosis of lunate necrosis. Handchir Mikrochir Plast Chir. 2001;33(6): p. 365-78. doi:10.1055/s-2001-19454
14. Ansari MT, Chouhan D, Gupta V, Jawed A. Kienböck's disease: where do we stand?. J Clin Orthop Trauma. 2020;11(4):606-613. doi:10.1016/j.j cot.2020.05.041
15. Allan CH, Joshi A, Lichtman DM. Kienbock's disease: diagnosis and treatment. J Am Acad Orthop Surg. 2001;9(2):128-136. doi:10.5435/00124 635-200103000-00006
16. Jaiswal AM, Shrivastava S, Dhanwani Y, Chandanwale R, Bhakaney PR. Managing kienbock disease's surgical treatment and outcome analysis: a case report and review of literature. Cureus. 2024;16(6):e63352. doi:10.7 759/cureus.63352
17. Tsantes AG, Papadopoulos DV, Gelalis ID, Vekris MD, Pakos EE, Korompilias AV. The efficacy of vascularized bone grafts in the treatment of scaphoid nonunions and Kienbock disease: a systematic review in 917 patients. J Hand Microsurg. 2019;11(1):6-13. doi:10.1055/s-0038-1677318
18. Hunter AR, Temperley D, Trail IA. Capitate shortening osteotomy and vascularized bone grafting for Kienböck's disease in ulnar positive or neutral wrists. J Hand Surg Eur Vol. 2021;46(6):581-586. doi:10.1177/1753 193421999915
19. Jiga L, Romanescu V, Jandali Z, Bürger H. Vascularized bone grafts from the lateral femoral condyle for the treatment of avascular lunate necrosis (Kienböck's). Indian J Orthop. 2023;57(7):1083-1091. doi:10.1007/s434 65-023-00877-8
20. Kakar S, Shin AY. Vascularized bone grafting from the dorsal distal radius for Kienböck's disease: technique, indications and review of the literature. Chir Main. 2010;29 Suppl 1:S104-S111. doi:10.1016/j.main.201 0.09.003
21. Park IJ, Kim HM, Lee JY, et al. Treatment of Kienböck's disease using a fourth extensor compartmental artery as a vascularized pedicle bone graft. J Plast Reconstr Aesthet Surg. 2016;69(10):1403-1410. doi:10.1016/j.bjps.2016.07.013
22. Ye X, Feng JT, Yin HW, Qiu YQ, Shen YD, Xu WD. Use of 4+5 extensor compartmental vascularized bone graft and K-wire fixation for treating stage II-IIIA Kienböck's disease. Hand Surg Rehabil. 2020;39(3):207-213. doi:10.1016/j.hansur.2020.01.005
23. Keith PP, Nuttall D, Trail I. Long-term outcome of nonsurgically managed Kienböck's disease. J Hand Surg Am. 2004;29(1):63-67. doi:10.1 016/j.jhsa.2003.10.016
24. Salmon J, Stanley JK, Trail IA. Kienböck's disease: conservative management versus radial shortening. J Bone Joint Surg Br. 2000;82(6):82 0-823. doi:10.1302/0301-620x.82b6.10570
25. Kayaokay K, Ozcan C, Bulut T, Gursoy M, Dirim Mete B. Radial shortening osteotomy vs partial capitate shortening osteotomy in Kienböck's disease: medium-term radiological and clinical results. Hand Surg Rehabil. 2021;40(4):427-432. doi:10.1016/j.hansur.2021.03.004
26. Dehghani M, Moshgelani MA, Nouraei MH, Dehghani S, Gholshahi M. Clinical outcomes of radial shortening osteotomy and vascularized bone graft in Kienböck's disease. Int Sch Res Notices. 2014;2014:956369. doi:10.1155/2014/956369
27. Gupta R, Pruthi M, Kumar A, Garg S. Outcome of Kienböck's disease in twelve cases: a mid-term follow-up study. Singapore Med J. 2014;55(11):58 3-586. doi:10.11622/smedj.2014155